- Humana (Topeka, KS)
- … (CMD) relies on medical background to review health claims and preservice appeals . The Corporate Medical Director works on problems of diverse scope ... and complexity ranging from moderate to substantial. The Corporate Medical Director provides medical interpretation and decisions regarding the… more
- Sanford Health (Sioux Falls, SD)
- …governing appeals and grievance resolution. Lead and manage the end-to-end appeals and grievances process for all product lines, ensuring compliance with ... state requirements. Oversee the intake, review, resolution, and documentation of all appeals , complaints, and grievances to meet regulatory and operational… more
- AmeriHealth Caritas (Philadelphia, PA)
- …for decision making or example, internal committee/panel, independent review organization, internal medical director - as process dictates + Provide support ... more about us at www.amerihealthcaritas.com. **Responsibilities:** Reporting to the Supervisor, Appeals and Grievances , this position is responsible for the… more
- Elevance Health (Atlanta, GA)
- …records of denied services for medical necessity. + Extrapolates and summarizes medical information for medical director , consultants and other external ... or overturn (approve) requested appealed service and forwards to Medical Director for final review and decision.... for final review and decision. + Ensures that appeals and grievances are resolved timely to… more
- Elevance Health (Costa Mesa, CA)
- …Prepares nurse summaries for Quality of Care cases and forwards to Medical Director for review and determination. + Ensures grievances are resolved timely to ... Appeals ** is responsible for investigating and processing and medical necessity appeals requests from members and...and Quality of Care cases. + Extrapolates and summarizes medical information for medical director .… more
- Elevance Health (Metairie, LA)
- …Prepares nurse summaries for Quality of Care cases and forwards to Medical Director for review and determination. + Ensures grievances are resolved timely to ... Appeals ** is responsible for investigating and processing and medical necessity appeals requests from members and...and Quality of Care cases. + Extrapolates and summarizes medical information for medical director .… more
- Cognizant (Washington, DC)
- …. Draft and submit the medical necessity determinations to the Health Plan/ Medical Director based on the review of clinical documentation in accordance with ... or clinic operations . Experience in utilization management to include Clinical Appeals and Grievances , precertification, initial and concurrent reviews .… more
- Sharp HealthCare (San Diego, CA)
- …the position, and employer business practices. **What You Will Do** This Senior Medical Director position provides critical management and oversight for Sharp ... + 5 years' experience as an HMO Health Plan Medical Director . + California Physicians and Surgeons...as needed.Completes and/or supervises the completion of all clinical appeals and grievances . Collaborates with Customer Care… more
- CVS Health (Tallahassee, FL)
- …resistant illnesses through peer review and educational interventions. * Work with medical director teams focusing on inpatient care management, clinical ... coverage review, member appeals clinical review, medical claim review, and...the investigation of potential quality of care concerns and/or grievances . * Actively support compliance functions to maintain standardized… more
- Molina Healthcare (Albuquerque, NM)
- …actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends or chairs committees ... + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the...activity (QIA) in collaboration with the clinical lead, the medical director , and quality improvement staff. +… more
- Molina Healthcare (Lincoln, NE)
- …actions. + Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. + Attends or chairs committees ... + Participates in and maintains the integrity of the appeals process, both internally and externally. Responsible for the...activity (QIA) in collaboration with the clinical lead, the medical director , and quality improvement staff. +… more
- State of Colorado (Jefferson County, CO)
- …Code of Regulations (CCR) 801-1, State Personnel Board Rules and Personnel Director 's Administrative Procedures, Chapter 8, Resolution of Appeals and Disputes, ... ASSISTANT DIRECTOR OF NURSING - MID-LEVEL PROVIDER Print (https://www.governmentjobs.com/careers/colorado/jobs/newprint/5120453)...Colorado. Admissions are for individuals with complex behavior and medical needs who may pose a risk to themselves… more
- UCLA Health (Los Angeles, CA)
- …UCLA Health Medicare Advantage Plan is looking for a dedicated and forward-thinking Associate Medical Director to help shape the future of our plan. In this ... key leadership role, you'll work closely with the UHMAP Medical Director and play a vital part...Provide clinical determinations for UM (prior authorizations, concurrent reviews, appeals , grievances , peer-to-peer). + Support day-to-day UM… more
- Sharp HealthCare (San Diego, CA)
- …as a physician executive in a managed care environment, preferably as an HMO Medical Director . + California Physicians and Surgeons License - Medical ... **Shift End Time** California Physicians and Surgeons License - Medical Board of CA; Doctor of Medicine (MD) **Hours**...+ Completes and/or supervises the completion of all clinical appeals and grievances . Collaborates with Customer Care… more
- Dignity Health (Bakersfield, CA)
- …support to the Medical Director of Utilization Management in medical review activities, peer-to-peer consultations, appeals and grievances and other ... offices primarily in the Bakersfield/Central CA region.** **Position Summary:** The Medical Director of Physician Engagement is responsible for developing… more
- Molina Healthcare (San Bernardino, CA)
- …actions. * Conducts retrospective reviews of claims and appeals and resolves grievances related to medical quality of care. * Attends or chairs committees ... JOB DESCRIPTION Job Summary Provides medical oversight and expertise in appropriateness and ...* Participates in and maintains the integrity of the appeals process, both internally and externally. * Responsible for… more
- UPMC (Pittsburgh, PA)
- The UPMC Health Plan is seeking a licensed MD or DO for a fully remote Medical Director , Utilization Management role. The Medical Director , Utilization ... improvement review processes, including concurrent, prospective and retrospective reviews, member grievances , provider appeals , and potential quality of care… more
- Guardian Life (Plano, TX)
- …compliant with applicable state regulations. You will ensure that claims, referrals, appeals , and grievances meet state specific regulations, timeframes, and ... The **Dental Director ** will be responsible for ensuring that professional...& ensure that determination and processing of claims, referralsand appeals meet state regulations, time frames& definitions. + Completeadjudication… more
- Independent Health (Buffalo, NY)
- …for the collection and review of medical records specific to quality complaints/ grievances and appeals as indicated in support of a high performing health ... Medical Director . This position will prepare written responses to appeals and complaints/ grievances , establish plans of correction and provide education… more
- UPMC (Pittsburgh, PA)
- The Medical Director , Utilization Management is responsible for assuring physician commitment and delivery of comprehensive high-quality health care to UPMC ... improvement review processes, including concurrent, prospective and retrospective reviews, member grievances , provider appeals , and potential quality of care… more
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